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Antibiotic stewardship in the NICU - what do you do in clinical practise?


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This paper (video abstract below!) came on my radar recently, that antibiotic stewardship works in the NICU, that initiation of antibiotics is reduced, length of tx is reduced etc.

A recent UK paper is a nice example of this, although most preterm infants in this paper still recieved antibiotics

I think we are pretty restrictive with antibiotics (as illustrated by this paper), but I feel we could have a more systematic approach...

How do you tailor antibiotics, and what tools do you use?

  • what makes you start?
  • what makes you stop?

 

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  • 3 weeks later...

We have changed our practice in the last few years. 

General rule is if SPTL, PROM, resp support required >4hrs (or Work of breathing / Fi02 req increasing earlier) or other risk factors present at delivery, we tend to initiate IV Abx on admission (Benzyl Penicillin and Gentamicin).  If repeat CRP is normal, no growth in culture and baby is well, we tend to stop Abx prior to 24hr dose (i.e. receive 2 doses BenPen and 1 dose Gent).

Also, if prolonged raised lactates but normal neurology, we tend to septic screen and initiate IV Abx.  Same scenario, stop at 24hrs if all okay, however, we have found a number of congenital infections in these infants.  Based on ongoing clinical picture, we would consider stopping Abx at 5-10 days but if meningitis, 2-3 weeks.

For LOS, we still do jump into early septic screen and IV Abx rather quickly due to rapidness of deterioration for our extreme prem infants.  We generally use Vanc and Gent (if central lines insitu) or Fluclox / Gent (if not lines) and usually stop prior to 48hr dose if no signs sepsis.  

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  • 2 weeks later...

I spoke to an american ANP at our 99nicu-Meetup who said that introducing the Kaiser score ( https://neonatalsepsiscalculator.kaiserpermanente.org/ )had really limited the antibiotic use in their unit. If I remember it correctly they had automated it into their digital journal system (Epic?).

I'm not sure why we don't use it, is it implemented anywhere in Europe? But as CRP seems to be insufficient, even though we use it in combination with IL-6/Procalcitonin, it might be a good complement. Are there any disadvantages with Kaiser?

The talk by Rene Kornelisse at the 99nicu meetup gave some food for thought on the subject of antibiotic use, let's see if we can publish it on the 99nicu Youtube-channel soon 🙂.

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